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Balloon Tamponade of Gastroesophageal Varices


Introduction

Managing patients with acute gastrointestinal bleeding from gastroesophageal varices can be one of the most challenging scenarios in emergency medicine. These patients often have advanced liver disease and can arrive at the emergency department (ED) with massive hematemesis, airway compromise, hemodynamic instability, critical anemia, thrombocytopenia, and coagulopathy. Gastroesophageal varices are the fourth most common cause of upper gastrointestinal bleeding (UGIB) and account for almost 12% of cases ( Fig. 41.1 ). In patients with cirrhosis, varices account for up to 80% of cases of UGIB. In patients with established gastric or esophageal varices, the annual incidence of acute hemorrhage ranges from 4% to 15%.

Figure 41.1, Endoscopic appearance of esophageal varices. A, Upper gastrointestinal endoscopy demonstrating dilated and straight veins (small esophageal varices) in the distal end of the esophagus (arrows). B, Upper gastrointestinal endoscopy demonstrating large esophageal varices, greater than 5 mm in diameter, with a fibrin plug (arrow) representing the site of recent bleeding.

Over the past 3 decades, advances in resuscitation, critical care, pharmacology, and endoscopy have significantly reduced the mortality rate associated with acute variceal bleeding. In fact, mortality rates in patients with acute variceal bleeding currently range from 15% to 20%. Despite advances in management, up to 20% of patients with acute variceal bleeding fail standard therapy. Rescue therapies for this group of patients are limited and include surgery, placement of a transjugular intrahepatic portosystemic shunt or a covered esophageal metal stent, or balloon tamponade. This chapter details the indications and contraindications for balloon tamponade in patients with acute variceal bleeding, the techniques for placement of the various devices, and the potential complications of this intervention. Although this procedure is rarely needed and placement in the ED is not considered a standard intervention, emergency physicians with knowledge of the technique can attempt to place these critical and potentially lifesaving devices.

Background

In 1950, Sengstaken and Blakemore developed and described the use of a double-balloon device to control variceal hemorrhage. Since that time, the Sengstaken-Blakemore tube ( ) has become the most widely known balloon tamponade device. The Sengstaken-Blakemore tube has an esophageal and a gastric balloon, along with a gastric aspiration port that allows continuous suction of stomach contents ( Fig. 41.2 ). In 1968, Edlich and colleagues, from the University of Minnesota, modified the Sengstaken-Blakemore tube by adding an esophageal aspiration port and increasing the capacity of the gastric balloon.

Figure 41.2, The Sengstaken-Blakemore (SB) tube. Note that this tube does not have esophageal aspiration ports; a nasogastric tube must be attached to the SB tube to allow esophageal suctioning (see text for details.)

Currently, three balloon tamponade devices are commercially available: the Linton-Nachlas, the Sengstaken-Blakemore, and the Minnesota tubes. In contrast to the Sengstaken-Blakemore and Minnesota tubes, the Linton-Nachlas tube is a single-balloon device that consists of a gastric balloon and two ports (esophageal and gastric) for aspiration and lavage. Because placement of these tubes remains a relatively rare procedure, most hospitals stock only one type of device. Regardless of the type of device, success rates for the control of hemorrhage with balloon tamponade tubes range from 60% to 90%.

Review Box 41.1, Balloon tamponade of gastroesophageal varices: indications, contraindications, complications, and equipment.

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